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We describe six patients with an identical type of headache, consisting of short episodes (lasting around 1 week) of daily attacks of ice-pick-like pain, recurring every minute in the same points of the scalp. In all of them, the pain was felt outside the cutaneous area of the trigeminal nerve (retroauricular, parietal, and occipital regions). All patients were examined in the emergency department of a general hospital over a period of 7 years because of these acute headaches. None of them had a history of migraine. Although this pain is identical to idiopathic stabbing headache, it differs from it by its temporal profile (in "status"), its posterior (extratrigeminal) location, and its lack of association with migraine. While the bouts were usually severe and recurred in two patients, all had a self-limited benign course and responded promptly to indomethacin.

Headache is the most frequent presenting symptom of cerebral venous thrombosis (CVT), most commonly associated with other manifestations. It has been described as its only clinical presentation in 15 % of patients. There is no typical pattern of headache in CVT. The objective of this study was to study the characteristics of headache as the sole manifestation of CVT. From a prospective study of 30 consecutive patients diagnosed with CVT over 18 months, we selected those who presented with headache only: they had a normal neurological examination, no papilloedema and no blood or any parenchymal lesion on CT scan. All were submitted to a systematic etiological workup and a structured questionnaire about the characteristics of headache was provided. Headache was the sole manifestation of CVT in 12 patients; it was diffuse or bilateral in the majority. Seven patients referred worsening with sleep/lying down, Valsalva maneuvers or straining. There was no association between the characteristics of headache and extension of CVT. Time from onset to diagnosis was significantly delayed in these patients presenting only with headache. In our series, 40 % of patients presented only with headache. There was no uniform pattern of headache apart from being bilateral. There was a significant delay of diagnosis in these patients. Some characteristics of headache should raise the suspicion of CVT: recent persistent headache, thunderclap headache or pain worsening with straining, sleep/lying down or Valsalva maneuvers even in the absence of papilloedema or focal signs.

Objective.-To compare patients with migraine and tension-type headache in their behavior during the attacks and the maneuvers used to relieve the pain.Background.-Patients with headache often perform nonpharmacological measures to relieve the pain, but it is not known if these behaviors vary with the diagnosis, clinical features, and pathogenesis.Methods.-One hundred consecutive patients with either migraine (n ϭ 72 ) or tension-type headache (n ϭ 28) were questioned (including the use of a checklist) concerning their usual behavior during the attacks and nonpharmacological maneuvers performed to relieve the pain. The results of the two types of headache were compared.Results.-Patients with migraine tended to perform more maneuvers than individuals with tension-type headache (mean, 6.2 versus 3). These maneuvers included pressing and applying cold stimuli to the painful site, trying to sleep, changing posture, sitting or reclining in bed (using more pillows than usual to lay down), isolating themselves, using symptomatic medication, inducing vomiting, changing diet, and becoming immobile during the attacks. The only measure predominantly reported by patients with tension-type headache was scalp massage. However, the benefit derived from these measures was not significantly different between the two groups (except for a significantly better response to isolation, local pressure, local cold stimulation, and symptomatic medication in migraineurs).Conclusions.-The behavior of patients during headache attacks varies with the diagnosis. Measures that do not always result in pain relief are performed to prevent its worsening or to improve associated symptoms. These behavioral differences may be due to the different pathogenesis of the attacks or to different styles of dealing with the pain. They can also aid the differential diagnosis between headaches in doubtful cases.

Migraine is highly prevalent and carries a significant personal, social and economic burden. It is the second cause of disability (years living with disability) worldwide and the first cause under 50 years of age. Chronic migraine (occurring for more than 15 days a month) and refractory migraine (treatment resistant), especially when there is also analgesic overuse, are the most disabling forms of migraine. These three disorders (chronic migraine, refractory migraine and medication overuse headache) are particularly difficult to treat. This article reviews their epidemiology, clinical presentation, diagnostic criteria, risk factors, comorbidities and social and personal impact. The therapeutic options available are discussed and focused on a multidisciplinary approach, non-pharmacological interventions treatment of comorbidities and avoiding analgesic overuse. Prophylactic treatments are mandatory and include the oral prophylactic treatments (topiramate), botulinum toxin type A and the novel monoclonal antibodies against calcitonin gene related peptide or its receptor, which are the first migraine preventive medicines developed specifically to target migraine pathogenesis. In refractory cases, multiple therapies are required including neurostimulation.

Background.-Some patients with otherwise typical cluster headache (CH) have persistent attacks free of cranial autonomic symptoms (CAS). The factors responsible for this atypical presentation are not known.Objectives.-To identify factors associated to the absence of CAS in patients with CH. Methods.-A prospective series of 157 patients with the diagnosis of CH was analyzed, comparing 148 typical CH patients with 9 CH patients without CAS.Results.-Patients without CAS reported significantly less intense attacks (P = .003) when compared to those with CAS. There was also a tendency (not reaching statistical significance) for a higher frequency of females and chronic CH among those without CAS. Otherwise, there were no differences between the two groups (in age, duration of illness, follow-up time, attack duration or frequency, nor side or site of pain). A logistic regression analysis showed that only pain intensity could explain the difference between the two groups, since the other explanatory variables were also associated with different intensity of attacks.Conclusions.-These results support the hypothesis that CH without cranial autonomic symptoms represents a milder form of CH.

IntroductionAutonomic disturbances in cluster headache (CH) are thought to result from parasympathetic stimulation [1] and from ocular sympathetic deficit [2] with expression of a Horner-like syndrome. Forehead sweating is though to be a consequence of a postganglionic lesion in sympathetic sudomotor fibres [3], with adaptive supersensitivity of the forehead sweat glands [4]. Facial flushing could result from a unilateral increase in extracranial blood flow, demonstrated during cluster attacks [5,6] as a consequence of trigeminal nociceptive activation [6,7].Principal component analysis is a data reduction method that explores correlations among the variables of a problem, producing a set of independent factors that resume the relation within the original variables -the principal components. We applied this deductive statistical method to the autonomic manifestations of a series of CH patients, trying to elucidate the relationships between these symptoms. MethodsThe Cluster Headache Outpatient database of Santa Maria's Hospital in Lisbon was used to select ICHD-II [8] CH patients. All patients included in this database was observed by neurologists with experience in headache. Clinical data were analysed, including age at first consultation, gender, duration of illness, follow-up time, pattern (episodic/chronic), presence of autonomic symptoms and number and type of autonomic symptoms (mio- Raquel Gil Gouveia Elsa Parreira Isabel Pavão MartinsAbstract The objective is to identify the pathogenesis of each autonomic manifestation in cluster headache (CH). Through a deductive statistics method (factor analysis) we analysed the type of autonomic symptoms reported by 157 CH patients. Three principal components were identified in the analysis: parasympathetic activation (lacrimation, conjunctival injection and rhinorrhoea), sympathetic defect (miosis and ptosis) and parasympathetic mediated effect (nasal congestion, eyelid oedema and forehead sweating). This work suggests that there are three different mechanisms underlying autonomic manifestations in CH.

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